Provider Demographics
NPI:1578671673
Name:JIM BOB EVERETT
Entity Type:Organization
Organization Name:JIM BOB EVERETT
Other - Org Name:EVERETTS PHARMACY SONORA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PIC
Authorized Official - Prefix:
Authorized Official - First Name:JIM
Authorized Official - Middle Name:BOB
Authorized Official - Last Name:EVERETT
Authorized Official - Suffix:
Authorized Official - Credentials:REG PHARMACIST
Authorized Official - Phone:325-387-2541
Mailing Address - Street 1:PO BOX 527
Mailing Address - Street 2:
Mailing Address - City:SONORA
Mailing Address - State:TX
Mailing Address - Zip Code:76950-0527
Mailing Address - Country:US
Mailing Address - Phone:325-387-2541
Mailing Address - Fax:325-387-5423
Practice Address - Street 1:417 HIGHWAY 277 N
Practice Address - Street 2:
Practice Address - City:SONORA
Practice Address - State:TX
Practice Address - Zip Code:76950-2204
Practice Address - Country:US
Practice Address - Phone:325-387-2541
Practice Address - Fax:325-387-5423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
TX231823336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX23182OtherTEXAS STATE BOARD OF PHAR
TX145400Medicaid
TXB0134686OtherDPS NUMBER
TXBE8778803OtherDEA NUMBER
TX145400Medicaid